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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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2
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Montoya Rodríguez A, Mayorga Duarte M, López SS, Obregón VR, López Marenco ME. Sub-segmental pulmonary thromboembolism in a pregnant woman with generalized lupus erythematosus, triple-negative antiphospholipid syndrome, and protein C deficiency. A case report. Radiol Case Rep 2024; 19:2249-2252. [PMID: 38532907 PMCID: PMC10963187 DOI: 10.1016/j.radcr.2024.02.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/28/2024] Open
Abstract
Autoimmune diseases and thrombophilic disorders, notably antiphospholipid syndrome (APS) and protein S deficiency, present a formidable challenge in pregnancy, substantially increasing the risk of thromboembolic complications by up to 20%. Pulmonary thromboembolism (PTE), characterized by a significantly higher maternal mortality rate, is of particular concern. APS, defined by the presence of antiphospholipid antibodies, emerges as a pivotal risk factor for PTE during pregnancy, especially in women exhibiting triple negativity. Concurrently, protein S deficiency further amplifies vulnerability to thromboembolic events, establishing a high-risk scenario for pregnant individuals. In a case involving a 29-year-old pregnant woman with a history of generalized lupus erythematosus, triple-negative antiphospholipid syndrome, and protein S deficiency, sudden-onset dyspnea prompted thorough investigation. Despite her complex medical history, a multidisciplinary approach led to the accurate diagnosis and successful management of subsegmental pulmonary thromboembolism, ensuring the well-being of both mother and fetus. Effectively managing PTE during pregnancy demands a comprehensive, multidisciplinary approach involving collaboration among obstetricians, internists, rheumatologists, and hematologists. Accurate diagnosis, tailored anticoagulation strategies, and continuous monitoring stand as indispensable pillars for maternal and fetal well-being.
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Affiliation(s)
- Arlin Montoya Rodríguez
- Department of Obstetric Critical Care and Internal Medicine, Bertha Calderón Roque Hospital, Managua, Nicaragua
| | - Mario Mayorga Duarte
- Department of Internal Medicine, Hilario Sánchez Vázquez Hospital, Masaya, Nicaragua
| | | | - Víctor Rosales Obregón
- Department of Nuclear Medicine, Nora Astorga National Radiotherapy Hospital, Managua, Nicaragua
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3
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Thachil R, Nagraj S, Kharawala A, Sokol SI. Pulmonary Embolism in Women: A Systematic Review of the Current Literature. J Cardiovasc Dev Dis 2022; 9:jcdd9080234. [PMID: 35893223 PMCID: PMC9330775 DOI: 10.3390/jcdd9080234] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular disease is the leading cause of death in women. Pulmonary embolism (PE) is the third most-common cause of cardiovascular death, after myocardial infarction (MI) and stroke. We aimed to evaluate the attributes and outcomes of PE specifically in women and explore sex-based differences. We conducted a systematic review of the literature using electronic databases PubMed and Embase up to 1 April 2022 to identify studies investigating PE in women. Of the studies found, 93 studies met the eligibility criteria and were included. The risk of PE in older women (especially >40 years of age) superseded that of age-matched men, although the overall age- and sex-adjusted incidence of PE was found to be lower in women. Risk factors for PE in women included age, rheumatologic disorders, hormone replacement therapy or oral contraceptive pills, pregnancy and postpartum period, recent surgery, immobilization, trauma, increased body mass index, obesity, and heart failure. Regarding pregnancy, a relatively higher incidence of PE has been observed in the immediate postpartum period compared to the antenatal period. Women with PE tended to be older, presented more often with dyspnea, and were found to have higher NT-proBNP levels compared to men. No sex-based differences in in-hospital mortality and 30-day all-cause mortality were found. However, PE-related mortality was higher in women, particularly in hemodynamically stable patients. These differences form the basis of future research and outlets for reducing the incidence, morbidity, and mortality of PE in women.
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Affiliation(s)
- Rosy Thachil
- Correspondence: ; Tel.: +718-918-5937; Fax: +(571)-376-6710
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4
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Imagerie de l’embolie pulmonaire chez la femme enceinte. IMAGERIE DE LA FEMME 2022. [DOI: 10.1016/j.femme.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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5
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Albricker ACL, Freire CMV, Santos SND, Alcantara MLD, Saleh MH, Cantisano AL, Teodoro JAR, Porto CLL, Amaral SID, Veloso OCG, Petisco ACGP, Barros FS, Barros MVLD, Souza AJD, Sobreira ML, Miranda RBD, Moraes DD, Verrastro CGY, Mançano AD, Lima RDSL, Muglia VF, Matushita CS, Lopes RW, Coutinho AMN, Pianta DB, Santos AASMDD, Naves BDL, Vieira MLC, Rochitte CE. Diretriz Conjunta sobre Tromboembolismo Venoso – 2022. Arq Bras Cardiol 2022; 118:797-857. [PMID: 35508060 PMCID: PMC9007000 DOI: 10.36660/abc.20220213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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6
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Zanotti-Fregonara P. Radiation Absorbed Dose to the Embryo and Fetus from Radiopharmaceuticals. Semin Nucl Med 2022; 52:140-148. [PMID: 35067360 PMCID: PMC8923960 DOI: 10.1053/j.semnuclmed.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nuclear medicine procedures are generally avoided during pregnancy out of concern for the radiation dose to the fetus. However, for clinical reasons, radiopharmaceuticals must occasionally be administered to pregnant women. The procedures most likely to be performed voluntarily during pregnancy are lung scans to diagnose pulmonary embolism and 18F-fluoro-2-deoxyglucose (18F-FDG) scans for the staging of cancers. This article focuses on the challenges of fetal dose calculation after administering radiopharmaceuticals to pregnant women. In particular, estimation of the fetal dose is hampered by the lack of fetal biokinetic data of good quality and is subject to the variability associated with methodological choices in dose calculations, such as the use of various anthropomorphic phantoms and modeling of the maternal bladder. Despite these sources of uncertainty, the fetal dose can be reasonably calculated within a range that is able to inform clinical decisions. Current dose estimates suggest that clinically justified nuclear medicine procedures should be performed even during pregnancy because the clinical benefits for the mother and the fetus outweigh the small and purely hypothetical radiation risk to the fetus. In addition, the fetal radiation dose should be minimized without compromising image quality, such as by encouraging bladder voiding and by using positron emission tomography (PET)/magnetic resonance imaging (MRI) devices or high-sensitivity PET scanners that generate images of good quality with a lower injected activity.
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Doruyter AGG, Holness JL. Dual energy window imaging for optimisation of P/V ratios in VP SPECT. EJNMMI Phys 2021; 8:69. [PMID: 34655369 PMCID: PMC8520548 DOI: 10.1186/s40658-021-00417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 10/01/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Ventilation–perfusion single-photon emission computed tomography (VP SPECT) plays an important role in pulmonary embolism diagnosis. Rapid results may be obtained using same-day ventilation followed by perfusion imaging, but generally requires careful attention to achieving an optimal count rate ratio (P/V ratio) of ≥ 3:1. This study investigated whether the ratio of counts simultaneously acquired in adjacent primary and Compton scatter energy windows (Eratio) on V SPECT was predictive of final normalised perfusion count rate (PCRnorm) on P SPECT using [99mTc]Tc-macroaggregated albumin (MAA), thus allowing for optimisation of P/V ratios. Methods Same-day VP SPECT studies acquired using standard protocols in adult patients during a 2-year period (training dataset) were assessed. Studies were included provided they were acquired with correct imaging parameters, and injection site imaging and laboratory records were available for quality control and normalised count rate corrections. Extraction of DICOM information, and linear regression were performed using custom Python and R scripts. A predictive tool was developed in Microsoft Excel. This tool was then validated using a second (validation) dataset of same-day studies acquired over a subsequent 7-month period. Accuracy of the prediction tool was assessed by calculating the mean absolute percentage error (MAPE). Results Of 643 studies performed, the scans of 342 participants (median age 30.4 years, 318 female) were included in the training dataset, the analysis of which yielded a significant regression equation (F(1,340) = 1057.3, p < 0.0001), with an adjusted R2 of 0.756 and MSE of 0.001089. A prediction tool designed for routine clinical use was developed for predicting final P/V ratio. Of an additional 285 studies, 198 were included in the second (validation) dataset (median age 29.7 years, 188 female). The Excel-based tool was shown to be 91% accurate (MAPE: 9%) in predicting P/V ratio. Conclusion The relationship between the ratio of simultaneously acquired counts in adjacent energy windows on V SPECT and perfusion count rate after administration of a known activity of [99mTc]Tc-MAA can be linearly approximated. A predictive tool based on this work may assist in optimising the dose and timing of [99mTc]Tc-MAA administration in same-day studies to the benefit of patients and workflows. Supplementary Information The online version contains supplementary material available at 10.1186/s40658-021-00417-z.
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Affiliation(s)
- A G G Doruyter
- NuMeRI Node for Infection Imaging, Central Analytical Facilities, Stellenbosch University, Cape Town, South Africa. .,Division of Nuclear Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - J L Holness
- Nuclear Medicine Division, Department of Radiation Medicine, University of Cape Town, Cape Town, South Africa
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8
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Vakili S, Shahbazi-Gahrouei D, Pourasbaghi P, Raeisi E. Investigation of fetal absorbed dose in V/Q scan in three trimesters of pregnancy using Monte Carlo simulation. World J Nucl Med 2021; 20:342-348. [PMID: 35018148 PMCID: PMC8686754 DOI: 10.4103/wjnm.wjnm_122_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/05/2020] [Accepted: 10/25/2020] [Indexed: 11/04/2022] Open
Abstract
The ventilation/perfusion (V/Q) single-photon emission computed tomography is the first method of diagnosis for pulmonary embolism in pregnant women. This study aimed to calculate the fetal absorbed dose and compare to recommended values in V/Q scan at three trimesters of pregnancy by Monte Carlo simulation (code MCNPX) using simulated phantoms, based on the adult female MIRD phantom. The collection of pregnant women phantoms (that of Stabin) was designed with changes in the MIRD phantom. Source organs were defined for each of the radiopharmaceuticals used in two scans, 133Xe and 81mKr for the lung and bladder and technetium diethylene-triamine-pentaacetate (99mTc-DTPA) aerosol for lung ventilation scan. Also, technetium macroaggregated albumin (99mTc-MAA) for lung ventilation scan, lung, bladder, and liver. Fetal absorbed dose was calculated and evaluated for the administration radiopharmaceuticals using the MCNP simulation output. For 200 MBq 99mTc-MAA, fetal absorbed dose was 1.01-1.97 mGy, which is higher than the values recommended by International Commission on Radiological Protection (ICRP). The same fetal absorbed dose was found for activities of 54 and 70 MBq in the third trimester. For 99mTc-DTPA-aerosol, fetal absorbed dose as a ventilation tracer was within the permitted range. For 133Xe and 81mKr, it was negligible. It is concluded that the fetus received the highest absorbed dose in the third trimester of pregnancy. For this reason, in this period of pregnancy, it is recommended to use the lower administration activity and her awareness must be done.
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Affiliation(s)
- Shahabeddin Vakili
- Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Daryoush Shahbazi-Gahrouei
- Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parastoo Pourasbaghi
- Department of Medical Physics, School of Medicine, Tarbiat Modares University, Tehran, Iran
| | - Elham Raeisi
- Department of Medical Physics and Radiology, School of Allied Medical Sciences, Shahrekord University of Medical Sciences, Shahrekord, Iran
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9
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Currie GM, Bailey DL. A Technical Overview of Technegas as a Lung Ventilation Agent. J Nucl Med Technol 2021; 49:313-319. [PMID: 34583954 DOI: 10.2967/jnmt.121.262887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Technegas is a carbon-based nanoparticle developed in Australia in 1984 and has been in widespread clinical use, including SPECT imaging, since 1986. Although 81mKr offers the ideal ventilation properties of a true gas, Technegas is considered preferred in more than 60 countries for ventilation imaging yet has limited adoption in the United States. In March 2020, a new U.S. Food and Drug Administration application was lodged for Technegas, and the impending approval warrants a detailed discussion of the technical aspects of the technology for those for whom it is new. Technegas is a simple yet versatile system for producing high-quality 99mTc-based ventilation studies. The design affords safety to patients and staff, including consideration of radiation and biologic risks. Technegas is the gold standard for the ventilation portion of SPECT-based ventilation-perfusion studies in pulmonary embolism and several respiratory pathologies. When approved by the U.S. Food and Drug Administration, Technegas will extend advantages to workflow, safety, and study quality for departments that adopt the technology.
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Affiliation(s)
- Geoffrey M Currie
- Charles Sturt University, Wagga Wagga, Australia; .,Baylor College of Medicine, Houston, Texas
| | - Dale L Bailey
- Royal North Shore Hospital, Sydney, Australia; and.,University of Sydney, Sydney, Australia
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10
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Bärenfänger F, Block A, Schmelz D, Hamami-Arlinghaus M. Individual calculation of perfusion activity based on ventilation efficiency for V/P-SPECT. Nuklearmedizin 2021; 60:278-282. [PMID: 33862660 DOI: 10.1055/a-1429-1832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Implementation of the individual calculation of perfusion activity to ensure the guideline-compliant ratio of perfusion to ventilation (P/V-ratio) of ≥ 3 in the diagnosis of acute pulmonary embolism (PE) using V/P-SPECT. MATERIAL AND METHODS 50 consecutive V/P-SPECT examinations, in which a standard activity of 160 MBq was applied for perfusion imaging, are evaluated retrospectively. Based on this patient group an activity factor is determined, which provides a correlation between the applied perfusion activity and the expected perfusion counts of the gamma camera. Using the mean activity factor, the perfusion activity required for a P/V-ratio of four is calculated using the previously acquired ventilation count rate. This is applied prospectively to the 100 subsequent examinations. RESULTS The mean perfusion activity factor is (54.56 ± 10.13) cps/MBq. The individually calculated perfusion activities range from 80 MBq to 200 MBq with an average value of (146.9 ± 35.3) MBq and a median of 140 MBq. The individual activity calculation thus reduced the mean perfusion activity by 8.2 % and the median by 12.5 %. In addition, the individual calculation reduced the proportion of P/V ratios < 3 from 14 % to 0 % and the proportion of P/V ratios > 5 from 24 % to 19 %. CONCLUSION The presented method for the individual calculation of perfusion activity offers a simple way to ensure a guideline-compliant P/V-ratio. Furthermore, unnecessarily high perfusion activity as a result of inadequate ventilation can be avoided.
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Affiliation(s)
- Felix Bärenfänger
- Institut für Medizinische Strahlenphysik und Strahlenschutz, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Andreas Block
- Institut für Medizinische Strahlenphysik und Strahlenschutz, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Detlef Schmelz
- Institut für Medizinische Strahlenphysik und Strahlenschutz, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Monia Hamami-Arlinghaus
- Klinik für Radiologie und Neuroradiologie - Abteilung für Nuklearmedizin, Klinikum Dortmund gGmbH, Dortmund, Germany
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11
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2045] [Impact Index Per Article: 681.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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12
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Happel C, Borowski M, Kamp A, Rudolf F, Wicke JH, Gröner D, Grünwald F, Fiebich M. [Prenatal Radiation Exposure in Nuclear Medicine]. Nuklearmedizin 2021; 60:233-239. [PMID: 33572000 DOI: 10.1055/a-1365-7954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Radiation exposure from nuclear medicine procedures during pregnancy may cause uncertainty among patients and medical professionals. In 2019, the German Society of Medical Physics (DGMP) and the German Society of Radiology (DRG) published a fully revised version of the report "Prenatal Radiation Exposure Arising from Medical Indication, Dose Calculation, Conclusions for Physicians and Pregnant Women". This report offers a basis for dose calculation and determination of radiation exposure to the unborn. This review summarizes the most notable general adaptions made in the report's newest version and specifically points out the changes relevant to the field of nuclear medicine.The DGMP report provides physicians and medical physicists with means to estimate prenatal radiation exposure to the unborn conservatively, in a prompt and comprehensible approach. The rapidly evolving field of indications in nuclear medicine and radiology gave rise to the initiative of profoundly revising the previous version of the report from 2002. It now accounts for the extended range of devices, nuclear medicine hybrid imaging and radiotracers recently introduced. The most extensive change is a shift from the former 3-step-concept for the dose calculation to a 2-step-concept. In diagnostic nuclear medicine the first step comprises a conservative approximation of radiation exposure on the basis of current diagnostic reference levels (DRL). If exposure is assessed to be below 20 mSv, risk to the unborn child is sufficiently low, no further approaches are considered necessary. If calculated doses exceed 20 mSv, for diagnostic studies without existing DRL or in case of radionuclide therapies step 2 requires dose calculation based on administered activity and the stage of pregnancy.The DGMP report on prenatal radiation exposure offers valuable guidance for physicians and medical physicists in the field of nuclear medicine. The calculation concept provides an important basis to estimate radiation exposure to the unborn. Its extensive revision in 2019 accounts for recent scientific and technical developments and a reform of the stepwise approach to dose estimation.
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Affiliation(s)
- Christian Happel
- Universitätsklinikum Frankfurt am Main; Klinik für Nuklearmedizin
| | - Markus Borowski
- Städtisches Klinikum Braunschweig; Institut für Röntgendiagnostik und Nuklearmedizin
| | - Alexandra Kamp
- Bundesamt für Strahlenschutz, Abteilung medizinischer und beruflicher Strahlenschutz
| | - Frank Rudolf
- Medizinische Hochschule Hannover, Stabsstelle Strahlenschutz und Abteilung Medizinische Physik
| | - Jan Henryk Wicke
- Medizinische Hochschule Hannover, Stabsstelle Strahlenschutz und Abteilung Medizinische Physik
| | - Daniel Gröner
- Universitätsklinikum Frankfurt am Main; Klinik für Nuklearmedizin
| | - Frank Grünwald
- Universitätsklinikum Frankfurt am Main; Klinik für Nuklearmedizin
| | - Martin Fiebich
- Technische Hochschule Mittelhessen Gießen; Institut für Medizinische Physik und Strahlenschutz
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13
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Tester J, Hammerschlag G, Irving L, Pascoe D, Rees M. Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature. J Med Imaging Radiat Oncol 2020; 64:505-515. [PMID: 32307898 DOI: 10.1111/1754-9485.13027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre-test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision-making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal-foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.
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Affiliation(s)
- Jodie Tester
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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14
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Bajc M, Lindqvist A. Ventilation/Perfusion SPECT Imaging Diagnosing PE and Other Cardiopulmonary Diseases. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Bajc M, Schümichen C, Grüning T, Lindqvist A, Le Roux PY, Alatri A, Bauer RW, Dilic M, Neilly B, Verberne HJ, Delgado Bolton RC, Jonson B. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. Eur J Nucl Med Mol Imaging 2019; 46:2429-2451. [PMID: 31410539 PMCID: PMC6813289 DOI: 10.1007/s00259-019-04450-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.
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Affiliation(s)
- Marika Bajc
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden.
| | - Carl Schümichen
- University of Rostock, Formerly Clinic for Nuclear Medicine, Rostock, Germany
| | - Thomas Grüning
- Department of Nuclear Medicine, University Hospitals Plymouth, Plymouth, UK
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, Clinical Research Institute, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ralf W Bauer
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt (Main), Frankfurt, Germany
| | - Mirza Dilic
- Clinic of Heart and Blood Vessel Disease, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Brian Neilly
- Department of Nuclear Medicine, Royal Infirmary, Glasgow, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Bjorn Jonson
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Goodacre S, Horspool K, Shephard N, Pollard D, Hunt BJ, Fuller G, Nelson-Piercy C, Knight M, Thomas S, Lecky F, Cohen J. Selecting pregnant or postpartum women with suspected pulmonary embolism for diagnostic imaging: the DiPEP diagnostic study with decision-analysis modelling. Health Technol Assess 2019; 22:1-230. [PMID: 30178738 DOI: 10.3310/hta22470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging. OBJECTIVE To estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging. DESIGN An expert consensus study to develop new clinical decision rules, a case-control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling. SETTING Emergency departments and consultant-led maternity units. PARTICIPANTS Pregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites. INTERVENTIONS Clinical features, decision rules and biomarkers. MAIN OUTCOME MEASURES Sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs. RESULTS The primary analysis involved 181 women with PE and 259 women without PE in the case-control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells's PE criteria (permissive), 0.577; and Wells's PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time - 0.669, B-type natriuretic peptide - 0.549, C-reactive protein - 0.542, Clauss fibrinogen - 0.589, enzyme-linked immunosorbent assay D-dimer - 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) - 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) - 0.524, prothrombin fragment 1 + 2 - 0.562, plasmin-antiplasmin - 0.639, Prothombin time - 0.613, thrombin generation lag time - 0.702, thrombin generation endogenous potential - 0.559, thrombin generation peak - 0.596, thrombin generation time to peak - 0.655, tissue factor - 0.531 and troponin - 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy. LIMITATIONS The findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care. CONCLUSIONS Clinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging. FUTURE WORK New diagnostic technologies need to be developed to detect PE in pregnancy. TRIAL REGISTRATION Current Controlled Trials ISRCTN21245595. FUNDING DETAILS This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kimberley Horspool
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Neil Shephard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Steven Thomas
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Judith Cohen
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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18
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Tromeur C, van der Pol LM, Le Roux PY, Ende-Verhaar Y, Salaun PY, Leroyer C, Couturaud F, Kroft LJM, Huisman MV, Klok FA. Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis. Haematologica 2018; 104:176-188. [PMID: 30115658 PMCID: PMC6312023 DOI: 10.3324/haematol.2018.196121] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/14/2018] [Indexed: 01/19/2023] Open
Abstract
Differences between computed tomography pulmonary angiography and ventilation-perfusion lung scanning in pregnant patients with suspected acute pulmonary embolism are not well-known, leading to ongoing debate on which test to choose. We searched in PubMed, EMBASE, Web of Science and the Cochrane Library databases and identified all relevant articles and abstracts published up to October 1, 2017. We assessed diagnostic efficiency, frequency of non-diagnostic results and maternal and fetal exposure to radiation exposure. We included 13 studies for the diagnostic efficiency analysis, 30 for the analysis of non-diagnostic results and 22 for the radiation exposure analysis. The pooled rate of false negative test results was 0% for both imaging strategies with overlapping confidence intervals. The pooled rates of non-diagnostic results with computed tomography pulmonary angiography and ventilation-perfusion lung scans were 12% (95% confidence interval: 8-17) and 14% (95% confidence interval: 10-18), respectively. Reported maternal and fetal radiation exposure doses were well below the safety threshold, but could not be compared between the two diagnostic methods given the lack of high quality data. Both imaging tests seem equally safe to rule out pulmonary embolism in pregnancy. We found no significant differences in efficiency and radiation exposures between computed tomography pulmonary angiography and ventilation-perfusion lung scanning although direct comparisons were not possible.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands .,Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, the Hague, the Netherlands
| | | | - Yvonne Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | | | - Christophe Leroyer
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Francis Couturaud
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
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19
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Chan WS. Diagnosis of venous thromboembolism in pregnancy. Thromb Res 2018; 163:221-228. [DOI: 10.1016/j.thromres.2017.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/10/2017] [Accepted: 09/04/2017] [Indexed: 01/24/2023]
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20
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Zanotti-Fregonara P, Hindie E. Performing nuclear medicine examinations in pregnant women. Phys Med 2017; 43:159-164. [DOI: 10.1016/j.ejmp.2017.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/28/2022] Open
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21
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Isidoro J, Gil P, Costa G, Pedroso de Lima J, Alves C, Ferreira NC. Radiation dose comparison between V/P-SPECT and CT-angiography in the diagnosis of pulmonary embolism. Phys Med 2017; 41:93-96. [DOI: 10.1016/j.ejmp.2017.04.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 12/14/2022] Open
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22
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Sheen JJ, Haramati LB, Natenzon A, Ma H, Tropper P, Bader AS, Freeman LM, Bernstein PS, Moadel RM. Performance of Low-Dose Perfusion Scintigraphy and CT Pulmonary Angiography for Pulmonary Embolism in Pregnancy. Chest 2017; 153:152-160. [PMID: 28823756 DOI: 10.1016/j.chest.2017.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The symptoms of normal pregnancy overlap those of pulmonary embolism (PE). Limited literature suggests that low-dose perfusion scanning (LDQ), which yields lower maternal-fetal radiation exposure than CT pulmonary angiography (CTPA), performs well in excluding PE in pregnant patients. METHODS We performed a retrospective cohort study of sequential pregnant women who underwent imaging for PE with LDQ or CTPA between 2008 and 2013 at Montefiore Medical Center. Our practice recommends LDQ for patients with negative results on chest radiographs. Patients were categorized according to initial imaging modality, and a subgroup analysis was performed in patients with asthma. The primary outcome was the negative predictive value (NPV) of imaging determined by VTE diagnosis within 90 days. RESULTS Of 322 pregnant women (mean age, 27.3 ± 6.3 years), initial imaging was positive for PE in 2.7% (6 of 225) of LDQs and 4.1% (4 of 97) of CTPAs, negative in 88.0% (198 of 225) of LDQs and 86.6% (84 of 97) of CTPAs, and indeterminate/nondiagnostic in 9.3% (21 of 225) of LDQs and 9.3% (9 of 97) of CTPAs (P = .79). Ten patients (3.1%) were treated for PE. The NPV was 100% for LDQ and 97.5% for CTPA. Subgroup analysis of patients with asthma (23.9% of this population) revealed a high likelihood of a negative study in the LDQ and CTPA groups (74.1% and 87.0%, respectively) and 100% NPV for both modalities. CONCLUSIONS PE is an uncommon diagnosis in pregnancy. LDQ and CTPA perform well, with less maternal-fetal radiation exposure with LDQ. Therefore, when available, LDQ is a reasonable first-choice modality for suspected PE in pregnant women with a negative result on chest radiograph.
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Affiliation(s)
- Jean-Ju Sheen
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Linda B Haramati
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Anna Natenzon
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Hong Ma
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Pamela Tropper
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Anna S Bader
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Leonard M Freeman
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Peter S Bernstein
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Renee M Moadel
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
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Zanotti-Fregonara P, Hindie E. Linear No-Threshold Hypothesis at the Hospital: When Radioprotection Becomes a Nosocomial Hazard. J Nucl Med 2017; 58:1355. [DOI: 10.2967/jnumed.117.190983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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24
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van Mens TE, Scheres LJJ, de Jong PG, Leeflang MMG, Nijkeuter M, Middeldorp S. Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev 2017; 1:CD011053. [PMID: 28124411 PMCID: PMC6464730 DOI: 10.1002/14651858.cd011053.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.
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Affiliation(s)
- Thijs E van Mens
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Luuk JJ Scheres
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mariska MG Leeflang
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
| | - Mathilde Nijkeuter
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University Medical Centre UtrechtDepartment of Internal MedicineHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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Algoritmo para el diagnóstico y el seguimiento de la tromboembolia pulmonar aguda. RADIOLOGIA 2017; 59:75-87. [DOI: 10.1016/j.rx.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/24/2023]
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26
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Hess S, Madsen PH. Radionuclide Diagnosis of Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:49-65. [DOI: 10.1007/5584_2016_105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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